Discussion:
In our case, excision of the MV apparatus predisposed to the LV rupture - a recognised complication following MV replacement, although its incidence has reduced with sparing of the native valve. The prolonged procedure and CPB time resulted in RV failure.
Acute RV failure is a well-recognized cause of morbidity and mortality following cardiac surgery. It is seen more often after left ventricular assist device implantation (20–30%), heart transplantation (2–3%) and only in 0.04–0.1% of patients following cardiac surgery.1
Patients with acute RV failure post-cardiotomy have a poor prognosis. In a series of 30 patients undergoing RVAD implantation for isolated RV failure following cardiac surgery over an 11-year period to 2012, 13 patients were successfully weaned from RVAD and of these, 10 survived to discharge. The median duration of support was 5 days.2
There have been 2 reports of insertion of an implantable RVAD following post-cardiotomy RV failure with successful weaning from the RVAD and explantation at 15 and 79 days of support, respectively.3,4 One patient developed a stroke and both needed redo sternotomy and surgery, which in itself is also associated with increased risk.
VA-ECMO was used initially as a bridge to recovery or decision in our unstable patient. ECMO provides adequate cardiopulmonary support in some instances but does not unload the ventricles to the degree possible with a ventricular assist device.
To our knowledge, this is the first report of the successful use of a percutaneous Protek Duo RVAD post-cardiotomy. The Protek Duo RVAD is a good option for short-term RV support in isolation or with other LV support devices for bi-ventricular support. However, it requires access to a hybrid theatre and Cardiology support, as well as input from cardiac surgeons and intensivists and was felt to be inappropriate as a first-line treatment. Percutaneously placed with IJV access and with an oxygenator added to the circuit, it provides both RV and respiratory support, and allows patient mobility and rehabilitation while on support.
This case illustrates that VA-ECMO can act as an effective short-term bridge to recovery or further support with a percutaneous RVAD. The case also shows that early and aggressive treatment of RV failure can have a positive outcome and this strategy should be considered in selected patients.